COVID-19 PRIMARY AND COMMUNITY CARE GUIDELINE

Version 4: 16/06/2020

COVID-19

PRIMARY AND COMMUNITY CARE GUIDELINE

IMPLEMENTATION PLANA

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Version 4: Primary and Community Care Covid-19 Framework/Pathway for Wales 16/06/2020 Page 2

CHANGES TO VERSION 4:

1. Terminology updated under 4 key health care actions to reference community integrated services page 4

2. Cluster Hub support changed to Community Integrated Services page 5

3. BAME added to higher risk category page 5

4. Learning disabilities added to higher risk category page 5

5. Chronic respiratory disease replaces COPD and asthma as reference to generic respiratory conditions page 5

6. Optimisation of frailty widened to reference optimisation of all higher risk groups page 6.

7. Algorithm on page 7 amended to include safety netting, reference to loss of smell/taste.

8. Algorithm on page 9 updated to include reference to AHP support, replace cluster hub support with community integrated services, and reminder that if patient is not suitable for ICU, they may still benefit from admission to hospital for oxygen therapy and non-invasive interventions

9. Updated web links on page 10

10. Added flowchart for management of borderline cases page 3


Version Control table:

V Date Changes Attachments

1 23/03/2020 N/A Covering letter AG Community telephone consultation LTC-COVID 19 Wellbeing support at home

v1 attachments.zip

2 31/03/2020 P6 flowchart: “admit to hospital” now clarified to “admit to acute hospital”

P6 rising respiratory rate reduced from >25 to >24

Advice to use airflow to the face eg a fan has been removed. This is no longer advised.

Covering letter Home oxygen

Pathway attachments v2.zip

3 08/04/2020 P8 References to support decision tree:

P19 NICE guidance on application of the clinical frailty score

NICE guidance on application of the clinical frailty score

Full NICE guidance (3/4/2020) https://www.nice.org.uk/guidance/ng165

4 16/06/2020 Terminology updated page 4

Cluster Hub support changed to Community Integrated Services page 5

Additions to higher risk category to include BAME and learning disabilities page 5

Reference to generic chronic respiratory disease replaces COPD and asthma page 5

Optimisation of frailty widened to reference optimisation of all higher risk groups page 6

Algorithm on page 7 amended to include safety netting and reference to loss of smell/taste.

Algorithm on page 9 updated to include reference to AHP support, replace cluster hub support with community integrated services, and reminder that if patient is not suitable for ICU, they may still benefit from admission to hospital for oxygen therapy and non-invasive interventions

Updated hyperlinks (page 10)

Added flowchart for management of borderline cases

Updated hyperlinks on self management/self-isolation (page 10):

https://phw.nhs.wales/topic

s/latest-information-on-

novel-coronavirus-covid-19/

https://assets.publishing.ser

vice.gov.uk/government/upl

oads/system/uploads/attac

hment_data/file/869144/Self

-

isolation_poster_for_patient

s.pdf Flowchart for management of borderline cases:

CAC Flow chart.CAC

(003) (002).docx

https://www.nice.org.uk/guidance/ng165

https://www.nice.org.uk/guidance/ng165

https://phw.nhs.wales/topics/latest-information-on-novel-coronavirus-covid-19/



https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/869144/Self-isolation_poster_for_patients.pdf








THE PRE-HOSPITAL MANAGEMENT OF COVID-19 INFECTION

Pathway Purpose

The purpose of this pathway is to support primary care, community and

paramedic colleagues in decision making regarding the management of

patients presenting with suspected or actual Covid-19.

Who will use it?

This entire framework/pathway is to be used by any doctor, nurse, paramedic

or allied health professional, anywhere in the community. Local Health Boards

and Clusters will plan and deliver their services differently according to local

needs and workforce, but will follow this framework.

Management Aim

We aim to treat all patients in a setting that is appropriate to their specific

personal needs, whilst maintaining a functioning healthcare system in

extraordinary circumstances. The framework provides a consistent approach to

the management of patients during the Covid-19 Pandemic and is aligned to

the all Wales secondary care guidance. It also complements PHW primary care

guidance.

The Four Key Health Care Actions in the Community

1. Self-Care and Self-management at home 2. Supportive Care delivered in the home, GP surgery or community

integrated services by a multi-professional team serving a cluster population

3. Palliative care delivered in the home, probably by a multi-professional cluster supportive care team

4. Referral to an acute hospital


KEY ASSUMPTIONS AND ENABLERS

Our ability to provide care as the number of patients infected with Covid-19

rises depends on a whole system approach to management. This model

assumes that:

That senior expert advice will be readily available by telephone

That we have access to patient information resources regarding

prognosis/clinical reasoning

The pathways are based on an ethical framework

That a Single Point of Access is available 24/7 for urgent referrals to

Community Integrated services and Palliative Care

That Community Integrated services and Palliative Care are able to

respond rapidly within 2 hours of a call and work collaboratively 24/7

That capacity and sickness is actively tracked on a daily basis to enable

new staff to redeploy and backfill gaps

That non-essential and admin tasks are removed from clinicians

(consider redeploying non-clinical staff to act as scribes, runners, etc)

That enhanced respiratory training is made available

That clinical governance arrangements are locally determined and may

need to change during the course of the pandemic.

Some patients are more likely to develop complications of Covid-19 and

require management which will be personalized according to their existing

conditions and circumstances.

Higher Risk Categories

o Elderly o BAME o Multi-morbidity o Learning disabilities o Long term conditions

o Respiratory o Cardiovascular, including Hypertension o Diabetes o Immunosuppressed


Key actions can be taken in advance

o Optimise the ability of the patient to resist infection and reduce complications.

o Optimisation of Long Term Conditions through clinical review and self-management

o Chronic respiratory disease o Diabetes o Hypertension o Cardiovascular disease

o Optimisation of care of vulnerable/higher risk groups as above o Medication reviews

o Co-produce an Advance Future Care Plan (with or without a DNA-CPR) that clearly describes the preferences of the patient for ceilings of treatment for the patient if possible


THE PRE-HOSPITAL ALGORITHM FOR COVID-19 INFECTION

111 Online/GP

A high temperature? A new continuous cough?

Loss of smell/taste

Atypical presentations may be common especially in the elderly

New Concerns

or Symptoms

Patient Calls

Own GP for

Telephone or Video

assessment

Self-Care at Home if

symptoms are mild

With safety-netting

This Community Framework/Pathway

should be read in conjunction with

PHW guidance for Primary Care. It

focuses on presenting symptoms and

clinical management irrespective

antigen or antibody test results

Safety-netting

no improvement in symptoms after 7 days AND/OR

worsening/non-resolving symptoms especially vomiting, breathlessness, fatigue, reduced ability to

perform activities of daily living

Emerging evidence suggests that people may not present with breathlessness despite significant hypoxia

Pay particular attention to high risk groups

Other features described include but not limited to eg GI upset, skin manifestations


Telephone or Video assessment

Emerging evidence suggests that people may not present with breathlessness despite significant

hypoxia – if uncertain a low threshold for pulse oximetry is advised

See specific safety netting advice on page 7

Self-Care at Home with

safety- netting

No further assessment

needed

Face to Face Clinical Assessment Required

In designated room in GP Practice or Cluster Hub or at home, using PPE

at local Hub or home using PPE

Patient requires emergency

treatment and is likely to benefit

from ICU escalation*

Admit to

Acute

hospital

Measure temp, pulse, BP, O2 sats and RR

Look for signs of respiratory distress - rising respiratory rate >24 and falling

SpO2<94% if no pre-existing respiratory disease (or 4% below baseline if known)

Use the three questions on page 7 to guide which action or

service is most likely to meet your patient’s needs

Discuss with front

door clinician and

admit/treat

accordingly

YES

NO


YES

Does your patient meet criteria

for respiratory distress?

Does patient have an advance

future care plan that applies in

this case?

a. YES – go to supportive/palliative care (community hub or Idris’ pathway)

2. Does patient have conditions or circumstances that mean secondary care

admission is not likely

to help?

a. NO – go to 4 b. YES - provide

supportive/palliative care (community hub or idris’ pathway)

3. Admit as emergency

Symptom relief, Self-Care at

Home with active monitoring

Involve community integrated

services for social/nursing/AHP

needs

NO

Yes

Palliative Care at Home NO

Community Integrated

Services Supportive Care at

Home

Community integrated

services Supportive Care at

Home with care plan

Admit to

Acute Hospital

If you are unsure if your patient should stay at home, we encourage you to speak to

a colleague or contact the local specialist advice line. Document all discussions.

Discuss admission

with front door

clinician and admit

/treat accordingly

*Evidence shows that the following groups do not respond well to ICU escalation:

Clinical Frailty Score of 5 or above (see link page 17 and further NICE guidance)

Chronic severe cardiac or respiratory disease and other severe co-morbidities

On home oxygen or undergoing palliative chemotherapy

* Many patients who would not benefit from ICU escalation will benefit from hospital admission for oxygen

therapy and other non-invasive interventions.


This pathway links to Self-isolation advice which can be accessed via:


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da

ta/file/869144/Self-isolation_poster_for_patients.pdf

Self-Care & Self-Management at Home





0 123

Referral logged by administration, triaged by Cluster Hub

Support Team and allocated a telephone consultation

appointment depending on urgency

Patient meets criteria and

has consented to referral

Referrer responsible for

next course of action

YES

Referrers:

Operational Hours:

Patient contacted via telephone using All Wales

Telephone Consultation Form. Clinical

intervention and further management dictated

by patient’s clinical condition

Referrer contacts team via

SPA and provides patient

details

Home visit

required

Further telephone

call

Patient well and

discharged with stay

at home advice

The following PPE MUST BE USED for consultations of acute respiratory infection or influenza like illness

Fluid Resistant Surgical Mask (FRSM)

Disposable gloves

Disposable plastic apron

Appropriate eye protection, after risk assessment of need, if splashing or spraying of body fluids likely.

For aerosol generated procedures (AGP) e.g. NIV/CPAP or suctioning YOU MUST use

FFP3 masks

Disposable gowns

Visors

Disposable gloves

PPE MUST BE USED IN CONJUNCTION WITH EFFECTIVE HAND HYGIENE For further information please refer to:

https://www.gov.uk/government/publications/wuhan-novel-coronavirus- prevention-and-control infection-

NO

Palliative Care

Continue

intervention as

clinically indicated

Discharged with Stay at home

advice

Clinical

management

Management is as for any viral pneumonia and is supportive

Encourage rest and oral fluid intake

Treatment for Pyrexia (Paracetamol)

Wheeze can be treated with bronchodilators

Steroids are not generally helpful and should be avoided unless there is another underlying respiratory condition.

Investigations are not generally required for the majority of cases

Cluster Hub Referral Pathway

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control







Please see appendices for additional cluster hub resources:

1. Patient Information Leaflet- Long term condition and pregnancy 2. Well-being support at Home 3. All Wales Community consultation form


Palliative care guidance in the context of Covid-19 epidemic

Palliative and end of life care in the community for patients who have

suspected severe COVID-19 infection, where not admitting to hospital is being

considered, and who are at risk of deterioration and death.

Advance & future care planning (ACP/FCP)

o If the patient is able to participate in decision making, support them

to do so.

o If they are not able to, find out whether any ACP/FCP or any kind of

statement of wishes has been written and make use of it. For

instance if there are clinical reasons not to admit, knowing that the

person wanted to avoid hospital admission may make the decision

and the discussion of it easier. Follow guidance on how to use.

o If there is none, think about whether there’s a chance to help write

down any preferences or priorities the person has. Follow guidance

on how to do this.

Symptom control

o Summary:

For breathlessness and anxiety, give a stat dose of morphine

2.5mg + midazolam 2.5mg by injection then start continuous

infusion of morphine 10mg + midazolam 10mg over 24h by

infusion via a syringe driver.

If already on a regular opioid, bigger starting doses may be

needed – see footnotes to table.

Use subsequent PRN doses freely.

Consider increasing both syringe driver and PRN doses if PRNs

are needed frequently, or if the response is incomplete. Seek

advice if this doesn’t work.

If there is concern about drug toxicity, eg respiratory

depression, seek advice.

Palliative Care at Home


Remember that deterioration including a fall in conscious

level is to be expected and does not mean toxicity. This

pattern in severe COVID-19 infection, in those patients who

are not expected to benefit from escalation, is likely to

represent deterioration in condition not drug toxicity.

o Experience of palliative and end of life care in severe COVID-19

infection is developing rapidly. Please look out for updates to this

guidance and use the most recent version.

o What we know so far is that severe COVID-19 infection can cause

severe and distressing symptoms that should respond well to quick

use of commonly used symptom control drugs. Because patients

may become very symptomatic very quickly, and deteriorate quickly,

symptom control is very urgent.

o General tips

Look for the common symptoms & ask if there are any others.

Establish what the priorities are. Usually at the end of life good

symptom control tops the list.

Explain what you’re doing, explain how it serves the priorities,

and explain that it is safe.

Adjust doses according to response. Some people need much

higher doses than others.

If they’re already taking regular strong opioids, ignore the

starting doses in the table & see footnotes.

These principles also work in end of life care for other illnesses.

There is more detailed symptom control guidance for non-

specialists here.

If you need advice having consulted that, ask. Local

arrangements are being confirmed.

o Common treatable symptoms of severe COVID-19 infection include

Breathlessness

Anxiety

Agitation

o Other symptoms may be due to the infection or due to pre-existing

long term or life-shortening conditions

Pain


Nausea & vomiting

Respiratory secretions

o Injectable drugs are likely to be needed. Subcutaneous is usual first

choice but intramuscular is OK. If the patient has suitable oral

medications and can take them then these can be used for now but

they’re likely to become unable to take them if they deteriorate so

don’t rely on these. Sublingual or buccal medications may remain an

option as the patient doesn’t need to swallow them, but in acute

distress they are harder to use.

o Sensible use of these drugs is safe and effective. We know that in

other conditions good symptom control in end of life care doesn’t

hasten death, and although experience of COVID-19 is more limited

there is no reason to think it’s different in this respect. Dose titration

may be required and sometimes to much higher doses.

o Some people with severe COVID-19 injection deteriorate very quickly

at the end of life. Injected doses work quickly, in about half an hour.

Use PRN doses freely to get control of the symptoms the patient has

now.

o These symptoms are expected to be continuous rather than

resolving, so if a syringe driver is available use that too to maintain

control. Syringe drivers start to work slowly if that’s all you do which

is why you need stat & PRN doses too. While syringe drivers are

useful, don’t rely on them alone for what the patient needs today. If

you are not able to set up a syringe driver, see if a nurse can visit

quickly to do so.

o If no syringe driver is available or if there is no one to set one up,

morphine + midazolam should be used at current PRN doses 4 hourly

by sc injection via a butterfly if someone is available to give it – this is

almost as effective as a driver and painless but needs round the clock

doses.

o If inadequate response, dose increases are likely to be needed. Get

advice if necessary.


Symptom Drug Route Starting dose1 (if not already on regular opioid)

Frequency

Breathlessness

Morphine6 Use together with midazolam

sc/im 2.5mg2 PRN up to hourly

sc Typically 10mg3 Over 24h by sc infusion

Oral4 5mg5 PRN up to hourly

Midazolam Use together with morphine

sc/im 2.5mg PRN up to hourly

sc Typically 10mg Over 24h by sc infusion

Lorazepam Use 1st line if no one to inject

Sublingual 500 micrograms PRN up to hourly

Oxygen Any Freely Continuous

Anxiety & agitation

Midazolam sc/im 2.5mg PRN up to hourly

Lorazepam Use 1st line if no one to inject

Sublingual 500 micrograms PRN up to hourly

Agitation (if hallucinations or if

treating as for anxiety hasn’t worked)

Haloperidol 1st line

sc/im 1.5mg PRN up to hourly

Sc Typically 3mg Over 24h by sc infusion

Levomepromazine sc/im 12.5mg

PRN up to hourly

Sc 25mg Over 24h by sc infusion

Nausea & vomiting Haloperidol sc/im 1.5mg PRN hourly

Pain Morphine sc/im 2.5mg

PRN up to hourly

Po 5mg PRN up to hourly

Respiratory secretions

Hyoscine hydrobromide

Sc 400 micrograms PRN up to 4 hourly

Glycopyrronium Sc 200 micrograms PRN up to 4 hourly

10mg oral morphine = 5mg morphine injection

Doses for pain and breathlessness are the same – keep it simple

1 Patients on regular opioids need, and tolerate, proportionately bigger

starting doses – standard doses will not work unless the existing dose is

quite small.

2 If already on regular oral morphine, to get the injected dose divide the

current PRN oral dose by 2. Alternatively divide the current total daily dose


(usually double the dose of 12 hourly oral morphine + any PRN doses) by

12. Either way is fine. Either way, round up – to the nearest 2.5mg if up to

10mg or to the nearest 5 if over 10mg.

3 If already on oral morphine, to get the syringe driver dose take the total

current 24 hour dose (usually double the dose of 12 hourly oral morphine +

any PRN doses) & divide by 2.

4 This must be immediate release eg oramorph, sevredol. Do not use

modified release for immediate relief of breathlessness – it takes too long

to work.

5 If already on oral morphine, to get the oral dose for breathlessness just use

their current PRN dose or divide the current total daily dose (usually double

the dose of 12 hourly oral morphine + any PRN doses) by 12.

6 If they are already taking a different strong opioid (eg diamorphine,

oxycodone, hydromorphone, fentanyl patch), for breathlessness you can

use whatever immediate release version they are taking for pain and at the

same dose. Give this + either midazolam or lorazepam. If an injection is

needed and their usual opioid isn’t available in injection form, just use

morphine.

5mg oral oxycodone = 5mg morphine injection. 1.3mg oral hydromorphone = 5mg morphine injection. Patients on fentanyl patches usually have immediate release morphine or diamorphine or sometimes oxycodone for pain so use that. You can consult symptom control guidance, or get advice.


National Guidance Secondary Care – Covid-19

Clinical Frailty Scale

https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf

Referral to Acute Hospital

FINAL3 All Wales

COVID-19 Secondary care Management Guideline.pdf




Decisions regarding treatment and hospital admission should be always be made on an

individual basis. NICE has issued a further statement on the application of the Clinical Frailty

Score :

“The CFS should not be used in younger people, people with stable long-term disabilities (for

example, cerebral palsy), learning disability or autism. An individualised assessment is

recommended in all cases where the CFS is not appropriate.”


ETHICAL FRAMEWORK Ethical summary statement

Some people benefit from rapid escalation to intensive care and ventilation. In

some patients this will not work. Some can be identified early. We should use

treatments that work, without disproportionate harm, subject to consent or

best interest judgments, and provided they can be offered within the

resources available. We should not use treatments that do not pass these

tests. A treatment, however widely used and well known and however much

the patient &/or those close to them think they would want it, should not be

used if it stands no real chance of working in a particular patient or if it would

cause disproportionate harm. Whatever treatments are being used, each

patient should be given the best care available, helping them to survive if that

can be achieved, and in all circumstances helping them to be comfortable, to

live with dignity, and to be in the place of their choice if that is important to

them. Guidance is offered to support decisions about which treatments will

help, which will not, and how to maintain comfort. For some patients, there is

nothing to gain by being in hospital. The question of what treatment is to be

used may therefore help decide where the patient should be. If all the

treatment being used can be done at home, and if some care is available,

home (including a care home if that is the person’s home) is usually the best

place and often the place they would prefer.

The best that is available may be less good than we would want to provide.

We should be as flexible as possible to get the patient as comfortable as

possible within the limitations we face. There may not be enough capacity to

offer every patient every treatment. Decisions not to use a treatment are

likely to be needed much more often during a pandemic crisis. Making sure

that patients are not given treatments that are not right for them helps them.

It also helps the other patients who may then have a greater chance to have

treatments that would work. This should be the basis of decisions and is the

fairest way to decide when there is not enough to go around.

Documents

COVID-19 PRIMARY AND COMMUNITY CARE GUIDELINE